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cardio.nstemi.post-pci-stent-thrombosis.v1

Post-PCI stent thrombosis (NSTEMI presentation)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.nstemi.core.v1 — narrowed to acute / subacute / late / very-late stent thrombosis per ARC definitions (Cutlip Circulation 2007 PMID 17470709) presenting as NSTEMI or STEMI-equivalent (TIMI 0 in-stent occlusion). Inherits parent universal regimen via routing; specialises emergent re-cath (door-to-balloon ≤90 min), escalation off clopidogrel to ticagrelor or prasugrel per TAILOR-PCI PMID 32840378 + ISAR-REACT 5 PMID 31475799, mandatory IVUS/OCT for mechanism (under-expansion, mal-apposition, edge dissection, neoatherosclerosis), selective IIb/IIIa for high thrombus burden / no-reflow, and extended DAPT (30 mo per DAPT trial PMID 25399658 OR ticagrelor 60 mg BID per PEGASUS PMID 25773268 in very-late events). Modifiable causes prioritised: premature DAPT cessation (most common — adherence intervention + bridge protocols documented), CYP2C19 LOF for clopidogrel (genotype-guided escalation per TAILOR-PCI), and IVUS-detected mechanical mal-deployment. Override path: hemodynamic / electrical instability OR recurrent in-stent thrombosis escalates to cangrelor bridge + IIb/IIIa + cardiogenic-shock engine + surgical revasc consideration. Status INTEGRATED authored 2026-05-15 by shard-06-cardio-acute as part of the Phase E NSTEMI-by-mechanism batch.

Entry points (4)

  • history
    Prior coronary stent + new ACS presentation — high pretest for stent thrombosis; ARC interval staging applies
    prior_pci_within_window_with_acs
  • imaging
    Angiographic in-stent filling defect or TIMI 0 occlusion at prior-stent segment — definite stent thrombosis per ARC
    angio_in_stent_thrombus
  • history
    Premature DAPT cessation (surgery, bleed, non-adherence) + new ACS — most common modifiable cause
    recent_dapt_interruption_with_acs
  • lab_abnormality
    Known CYP2C19 LOF allele on clopidogrel + breakthrough event — escalation indication per TAILOR-PCI
    cyp2c19_lof_known_with_breakthrough

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Age affects antiplatelet selection (prasugrel CONTRAINDICATED >75); influences IVUS/OCT use thresholds
  • weightrequired
    demographic • used at CONTEXT
    Prasugrel CONTRAINDICATED <60 kg; weight-based heparin/IIb/IIIa
  • prior_pci_detailsrequired
    history • used at CONTEXT
    Stent type (DES vs BMS), date, location, lesion complexity drive ARC interval + likely mechanism (mal-apposition, neoatherosclerosis in late/very-late)
  • dapt_status_and_interruptionsrequired
    history • used at CONTEXT
    Current DAPT regimen + recent interruptions (surgery, dental, bleed) — most common cause of acute/subacute thrombosis per EAPCI 2014
  • cyp2c19_genotype_if_known
    history • used at CONTEXT
    CYP2C19 LOF (*2/*3) → clopidogrel non-response; TAILOR-PCI PMID 32840378 supports genotype-guided escalation
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic instability common with large in-stent thrombus → MCS standby per DanGer Shock
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    Confirms NSTEMI/STEMI biomarker pattern per ESC 2023 0/1-h algorithm
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Re-cath contrast nephropathy risk; eGFR for AC dosing
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Hgb baseline before triple antithrombotic + IIb/IIIa; platelets for HIT/ITP rule-out (rare differential)
  • ecg_serialrequired
    imaging • used at INITIAL_WORKUP
    Serial ECG; in-stent thrombosis frequently presents as STEMI (TIMI 0 occlusion) → primary PCI triage
  • cor_angio_emergentrequired
    imaging • used at BRANCHING_WORKUP
    Emergent angiography confirms in-stent thrombus location and TIMI flow; gates IVUS/OCT use
  • ivus_or_oct_intraproceduralrequired
    imaging • used at BRANCHING_WORKUP
    IVUS/OCT identifies mechanism (under-expansion, mal-apposition, edge dissection, stent fracture, neoatherosclerosis) — drives PCI strategy and long-term plan

12-phase flow (12)

  1. 1FRAME
    Suspect stent thrombosis in any prior-PCI patient with new ACS; classify per ARC interval (acute / subacute / late / very-late) and DAPT-interruption history; route to parent cardio.nstemi.core.v1 for the universal regimen plus emergent re-cath workflow
    inputs: prior_pci_details, ecg_serial, hs_troponin_serial
    advance: Stent-thrombosis suspicion documented
  2. 2ENTRY
    Activate cath lab — most stent thromboses present as STEMI-equivalent with TIMI 0; aggressive antithrombotic load + door-to-balloon ≤90 min
    inputs: age, weight
    advance: Cath lab activated
  3. 3CONTEXT
    Reconcile DAPT regimen + interruptions (surgery, bleed, non-adherence, drug holidays), prior CYP2C19 genotype if known, prior IVUS/OCT findings from index PCI, prior antiplatelet response testing if any
    inputs: dapt_status_and_interruptions, cyp2c19_genotype_if_known, sbp, creatinine_egfr
    advance: Antithrombotic context complete
  4. 4RED_FLAGS
    Hemodynamic instability with large in-stent thrombus → MCS standby + cardiogenic shock screen; recurrent in-stent thrombosis → CYP2C19 + IVUS retrospection; new mechanical complication if MI completed
    inputs: sbp
    actions: acs_pathway, cardiogenic_shock
    advance: Red flags screened
  5. 5INITIAL_WORKUP
    Serial ECG, 0/1-h hsTn, BMP, CBC (incl plt for HIT differential), coags, type-and-screen pre-cath, lipids, A1c
    inputs: ecg_serial, hs_troponin_serial, creatinine_egfr, cbc
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Pre-cath workup complete
  6. 6BRANCHING_WORKUP
    Emergent angiography confirms in-stent thrombus; IVUS or OCT during PCI mandatory for mechanism — under-expansion / mal-apposition / edge dissection / neoatherosclerosis (very-late) — directly drives PCI strategy and lifelong plan
    inputs: cor_angio_emergent, ivus_or_oct_intraprocedural
    actions: chest_pain
    advance: Mechanism documented intraprocedurally
  7. 7DIFFERENTIAL
    In-stent thrombosis vs in-stent restenosis vs new lesion vs spontaneous coronary dissection vs vasospasm vs embolic — IVUS/OCT typically discriminates
    advance: Mechanism confirmed
  8. 8RISK_STRATIFICATION
    Compute HEART/TIMI/GRACE for parent context; document ARC interval; identify modifiable causes (DAPT interruption, CYP2C19 LOF, mechanical mal-deployment) + extended-DAPT eligibility (DAPT score)
    inputs: age, sbp, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.has_bled, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: Mechanism + extended-DAPT decision documented
  9. 9TREATMENT
    Aggressive upfront load — ASA + escalated P2Y12 (ticagrelor preferred OR prasugrel if no contraindication) + UFH per ACT (250-300 during PCI); selective GP IIb/IIIa (eptifibatide / tirofiban) for high thrombus burden or no-reflow; aspiration thrombectomy if very high burden; high-intensity statin; mechanism-directed PCI with IVUS-guided stent optimisation
    inputs: creatinine_egfr, cbc
    actions: protocol.stemi
    advance: Mechanism-directed PCI complete + escalated DAPT regimen
  10. 10DISPOSITION
    CICU post-PCI for monitoring of recurrent thrombosis + bleed (triple antithrombotic risk); cardiology + interventional cardiology consult for long-term plan
    advance: CICU disposition + IVUS findings documented
  11. 11MONITORING
    Continuous ECG/SpO2 for recurrent ischemia; CBC q4-6 h × 24 h on IIb/IIIa or triple antithrombotic per BARC 2011; ACT during PCI; bleeding signs each shift
    inputs: creatinine_egfr, cbc
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Extended DAPT 30 mo (DAPT score ≥2) per Mauri NEJM 2014 OR ticagrelor 60 mg BID per PEGASUS PMID 25773268 if very-late thrombosis; CYP2C19 testing if not done (TAILOR-PCI); cardiac rehab; aggressive lipid + adherence reinforcement; consider IVUS-guided PCI for any future intervention
    advance: Extended-DAPT plan + adherence + secondary-prevention bundle finalised